Ovid Technologies (Wolters Kluwer Health)

Controversy persists regarding the protocol for tensioning and securing the grafts in one-stage reconstruction of combined anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) injuries. Many authors have reported stability examinations and functional results after reconstruction for this relatively rare injury, and the best sequence for tensioning the grafts is not known. We sought to determine (1) if there are differences in postoperative anteroposterior stability in a protocol of simultaneous tensioning of both grafts and ACL-first fixation compared with a protocol of tensioning and fixation of the PCL first in one-stage reconstruction of combined ACL/PCL injuries; and (2) if there is a difference in postoperative functional outcome scores between the two protocols. Between 2001 and 2011, 29 patients underwent one-stage reconstruction of combined ACL and PCL injuries (the majority with medial collateral ligament [MCL] injuries, posterolateral corner [PLC] injuries, or both, in addition), of whom three patients (10%) were lost to followup before 2 years, and one patient was excluded based on predefined criteria, leaving a total of 25 patients (86%) for retrospective analysis in this report. Fourteen patients underwent one-stage reconstruction of these injuries with tensioning and fixation of the PCL graft first (PCL-first group), and 11 later patients underwent one-stage reconstruction of combined ACL/PCL injuries with simultaneous tensioning of both grafts and fixation of the ACL graft first (simultaneous-tensioning group). During the period in question, the technique used in the PCL-first group was used exclusively for these injuries between August 2001 and August 2008 and that used in the simultaneous-tensioning group was used between September 2008 and August 2011; there was no overlap between groups. The groups were similar in terms of demographics and length of followup. Each patient was assessed for associated injuries, preoperative and postoperative knee stability with anteroposterior stress radiographs, and was evaluated with the Lysholm knee score and International Knee Documentation Committee (IKDC) subjective and objective grading at the last followup after surgery. At the last followup evaluation, patients treated with simultaneous tensioning and ACL-first fixation showed less instability on side-to-side difference of posterior stress radiography (5 ± 1 mm in the simultaneous-tensioning group versus 6 ± 1 mm in the PCL-first group; effect size, 1.2; 95% confidence interval [CI], 0.5–2.3; p = 0.011), but with the numbers available, no difference on anterior stress radiography (3 ± 0.4 mm in the simultaneous-tensioning group versus 3 ± 0.5 mm in PCL-first group; effect size, 0.4; 95% CI, −0.2 to 0.5; p = 443). The simultaneous-tensioning group also had higher Lysholm knee scores (87 ± 5 in the simultaneous-tensioning group versus 80 ± 4 in the PCL-first group; effect size, 1.8; 95% CI, −10.9 to −2.7; p = 0.001), IKDC subjective scores (68 ± 3 in the simultaneous-tensioning group versus 58 ± 3 in the PCL-first group; effect size, 3.4; 95% CI, −14.2 to −8.6; p < 0.001), and IKDC objective grades (p = 0.037). In one-stage reconstruction of combined ACL and PCL injuries, a protocol of simultaneous tensioning both grafts and fixing the ACL graft first may be worth consideration. Arthroscopic reduction landmarks may prove helpful in this technique but require further validation. Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

The Saltzman-el-Khoury hindfoot alignment view (HAV) is considered the gold standard for assessing the axis from hindfoot to tibia. However, it is unclear whether radiographic alignment influences dynamic load distribution during gait. We evaluated varus-valgus alignment by the HAV and its influence on dynamic load distribution in ankle and tibiotalocalcaneal (TTC) arthrodesis. We clinically assessed 98 patients (ankle, 56; TTC, 42) with SF-36 and American Orthopaedic Foot and Ankle Society (AOFAS) scores, visual hindfoot alignment, HAV angle, and dynamic pedobarography using a five-step method. For comparison, 70 normal feet were evaluated. Minimum followup was 2 years (average, 4.11 years; range, 2–6 years). The mean HAV angle was −0.8° ± 7.8° for ankle and −1.2° ± 6.9° for TTC arthrodesis. The HAV angle correlated with pedobarographic load distribution (r = 0.35–0.53). Radiographic alignment did not influence SF-36 or AOFAS scores; however, load distribution correlated to qualities of these scores. Visual alignment only predicted the corresponding HAV angle in 48%. To reproduce the dynamic load of healthy subjects, HAV angles of 5° to 10° valgus were needed. Visual positioning is inadequate to determine intraoperative positioning and resulted in a varus position with a relatively large SD. The HAV should be used to assess the hindfoot alignment correctly. HAV angles of 5° to 10° valgus are needed to reproduce a physiologic gait pattern.

Arthroplasty for shoulder fractures is a technically challenging and unpredictable procedure and its use is controversial. We therefore asked (1) to what degree function would be restored, (2) whether tuberosity healing would reliably occur, and (3) whether stem design would influence function in patients treated with hemiarthroplasty for proximal humerus fracture. We retrospectively reviewed all patients treated with a hemiarthroplasty for proximal humeral fracture between September 2001 and May 2006. The first 58 patients (September 2001 to March 2004) were treated with a conventional humeral prosthesis. The next 112 patients (April 2004 to May 2006) were treated with a fracture-specific humeral prosthesis. Clinical measures (American Shoulder and Elbow Surgeons scores, visual analog pain scores, and goniometric measurements of glenohumeral motion) and radiographic evaluation of tuberosity healing were performed at minimum 24-month followup (mean, 32 months; range, 24–96 months). Mean active anterior elevation was 118°, mean active external rotation 37.6°, and mean American Shoulder and Elbow Surgeons score 66. Overall, 127 of 170 (75%) greater tuberosities healed. With respect to stem design, active anterior elevation, active external rotation, and American Shoulder and Elbow Surgeons score were better with fracture-specific stems (129.8°, 39°, and 72, respectively) than with conventional stems (95.4°, 33.0°, and 55, respectively). Fewer tuberosities healed with conventional stems (38 of 58, 66%) than with fracture-specific stems (89 of 112, 79%). The use of fracture-specific stems during proximal humeral hemiarthroplasty for fracture appears to improve functional use of the injured shoulder and tuberosity healing compared to conventional stems. Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Identification of biomarkers associated with wear and tribocorrosion in joint arthroplasty would be helpful to enhance early detection of aseptic loosening and/or osteolysis and to improve understanding of disease progression. There have been several new reports since the last systematic review (which covered research through mid-2008) justifying a new assessment. We sought to determine which biomarkers have the most promise for early diagnosis and monitoring of aseptic loosening and/or osteolysis related to wear or corrosion in total joint arthroplasty. We performed a systematic review using MEDLINE and EMBASE databases, covering the period through December 2013, and identified 1050 articles. We restricted the definition of biomarker to biomolecules and imaging parameters useful for diagnosis and monitoring of disease progression, only including articles in English. We chose 65 articles for full review, including 44 from the original search and 21 from subsequent hand searches. We used the 22 articles in which patients with total joint arthroplasty who had aseptic loosening and/or periimplant osteolysis unrelated to sepsis had been compared with patients with total joint arthroplasty with stable implants. There were 90 comparisons of these two patient populations involving 35 different biomarkers. Diagnostic accuracy was assessed in nine of the 90 comparisons with the highest accuracy found for tartrate-resistant acid phosphatase 5b (0.96), although a separate comparison for this biomarker found a lower accuracy (0.76). Accuracy of > 0.80 was also found for crosslinked n-telopeptide of type I collagen, osteoprotegerin, and deoxypyridinoline. The most studied markers, tumor necrosis factor-α and interleukin-1β, were found to differ in the affected and control groups in < 30% of the comparisons. Thirty of the 35 biomarkers were studied in four or fewer separate comparisons with nearly half of the biomarkers (17) studied in only one comparison. Many of the comparisons were not able to eliminate a number of confounding variables, and there was only one prospective study. Currently, there are no validated biomarkers for early diagnosis and monitoring of the biological sequelae of wear or tribocorrosion, although there are some promising leads, including markers of bone turnover.

Injuries are a major worldwide contributor to morbidity and mortality. The negative impact caused by such injuries is disproportionately heavy in developing countries. Such disparities are caused by a complex array of problems, including a lack of physical resources, poor infrastructure, and a shortage of trained health professionals. Overcoming such deficits in care will require the involvement of organizations that can offer broad-based solutions. These organizations must bridge the gap between private and public institutions to establish a systems-based approach to program development and institution-building. They must provide not just an adequate level of care, but a transfer of knowledge that leads to sustainable and cost-effective intervention. Orthopedics Overseas is an example of such an organization. We examine the development of Orthopedics Overseas and describe their interventions in Uganda as a case-study to show the unique position they have to affect change.